Report Request Form

Data Analytics Center Report Request Form Page 1/3

Please email this to and in the subject line please put “Data Analytics Center Report Request”. All items with the red * are required to be completed.

Date: Tuesday, August 26, 2014

Requester Contact Information*:

Name:

Department:

Email (UPHS or PSOM): Phone:

Previous Report Name / ticket #:

Request Approved By:

Request Title*:

Purpose*:

Please provide specific details on the objectives or abstract of your request. This will better help us meet your specific needs.

Type of Analysis *(Please indicate the appropriate type):

Compliance, QA, Patient Care
Funded IRB Approved Research (attach IRB Approval and Protocol)
Non-funded IRB Approved Research (attach IRB Approval and Protocol)
Preparatory Research
Professional Billing
Other (Describe):

Research Program - Is the PI performing this study for a thesis for a mentored degree program, eg the MPH, MSCE, MSHP, MSME, or PhD? YES or NO

Expected Report Delivery Date:

Report Format (e.g. Excel, flat file, PDF, etc):

Report Frequency - Ambulatory Clinical Reports Only

( ) One-Time Ad-Hoc ( ) Scheduled

For schedule reports how often:

Who will the report get distributed to (email address):

Define Parameters Required*

Note: The more specific you can be the better our team will be able to meet your needs in an expedited manner. If you are not specific in your criteria(s), the request may be denied and delay the process.

Criteria / Display? / Description / Exclusions / Limitations / Filters
MRN
Visit ID
Patient Class(es)
Please select only which class(es) you will need. / ⃝ Inpatient
⃝ Outpatient
⃝ Emergency
Age or DOB ranges
Gender
Race
Department(s)
Provide department numbers not just names.
Provider(s)
Provide ID’s not just names.
Date(s)
Include in the specific range and date types (eg, admit, order, result)
Procedure
Please include the specific procedure codes. (ICD9 is preferred for inpatient)
Diagnosis
Please include the specific ICD-9 codes including all decimal points. Do not simply include ranges or wildcards.
Orders
Medication
Please list as it is ordered within the UPHS EMR’s – medication id’s preferred
Lab Result
Please list the lab as it is ordered within the UPHS EMR’s.
Other
Other
Other
Other
Other

Fields to display on report

Data calculations needed (e.g. average, sum, etc)

Data Grouping (e.g. by patient, by day, by procedure, by Department, etc)

Report Layout (draw out/describe as expected):